Esophagopericardial fistula: an unexpected dreaded complication of treatment of leak following revisional sleeve gastrectomy by endoscopic internal drainage

A 31-year-old woman, who underwent revisional sleeve gastrectomy (RSG) 12 days ago in another hospital, was admitted in our multidisciplinary care team dedicated to the management of bariatric complications, with severe sepsis. Emergent chest and abdominal computed tomography (CT) scan showed a deep-seated abscess in link with a fistula on the upper third of the staple line. Surgical revision was performed to treat peritonitis and included abdominal washout, abdominal drainage close to the staple line and a feeding jejunostomy, respectively. Medications included proton pump inhibitors, appropriate antibiotics, somatostatin analogs and exclusively parenteral nutrition followed by enteral nutrition via the feeding jejunostomy. After the initial re-operation, percutaneous drainage (using 14Fr and 10Fr external pigtail drains, respectively) was required on postoperative day (POD) 8 due to persistent intra-abdominal abscess on CT scan. During follow-up, a plastic 4 cm x 10 French double pigtail drains was placed on POD 21 through the staple line orifice by endoscopy (Figs 1 and 2). External drainage (inserted during radiological procedure on POD 8) was removed 3 days later not only because of clinical and biochemical patient's improvement but also to avoid the development of an external fistula.

On POD 13, the patient experienced retrosternal pain, breathlessness, tachycardia (110 beats per minute) and pyrexia (38.5°C). Initial workup demonstrated negative cardiac biomarkers, but inflammatory markers were raised. Electrocardiography revealed ST-segment elevation in precordial leads, which suggested acute pericarditis. Transthoracic echocardiography revealed a significant circumferential pericardial effusion without signs of tamponade. Chest CT scan performed emergently confirming a fistula between the pericardium and the esophagus related to the proximal end of the double pigtail drain (Figs. 3–6). Hemodynamic and respiratory instability emerged during CT scan. Stabilization was achieved with catecholamines and fluids and the multidisciplinary team decide to operate urgently. Therefore, a right-sided thoracotomy was used to enter the pleural cavity through the seventh intercostal space. The intraoperative situs showed a 15-mm defect of anterior side of the esophagus with penetration to the pericardium. A pericardial incision was performed in order to evacuate turbid fluid followed by a pericardial window for continuous drainage. Double pigtail drains around inferior vena cava were removed. Because of severe sepsis, the esophagus was defunctioned with a cervical esophagostomy, a gastrostomy and a previous feeding jejunostomy. The postoperative period was uneventful and the patient was discharged on POD 40. An elective reconstruction of his esophagus with the colon will occur 6 months later.